Cardioversion, sooner or later

This is a question for folks who have had successful cardioversions.

My cardiologist attempted cardioversion, unsuccessfully, on one occasion, a couple of years ago, now. He tried twice, and I returned to afib both times. My episodes typically last 18 hours or so, though the most recent went 28 hours before resolving itself.

What I am curious to know is, for those of you who have undergone successful cardioversion: Was it relatively early in your typical episode, or later? My attempt at cardioversion happened within the first third or so of my typical episode. I'm wondering if I should wait a while...maybe give it 12 hours before attempting cardioversion.

I suppose you could say "If you're going to convert in 6-12 hours anyway, why go to the trouble?" I suppose I'm just trying to be prepared, in case 24+ hours is going to become my new "normal."

For background, my episodes typically start in the late afternoon or early evening, though the two most recent started at 1pm and 9am.

Curious if you've tried or thought about on-demand (PIP - Pill in Pocket) rhythm med like flecainide. If it works and you tolerate, seems like it would be something you could do at the very beginning of an episode. In my case, I've done this for nearly 16 years (including converting a 2 1/2 month episode at the beginning of that period). Any more, I've titrated my afib remission program to the point I have to do it very infrequently (twice in last two years, with the last time in April 2019).

I've had three. The only one that worked was performed more than 14h after my afib appeared.
Back then, my episodes did last 15-20h and stopped spontaneously.
The other two ECV were tried shortly after my afib had kicked in. Didn't work even at 300J. I self converted less than 24h after.

Not going to count my first ECV. Had several episodes that lasted 24/36 hours and self-converted by adding an extra flecanide to my regimen. Last episode, additional flecainide did not help, I did not self-convert, and was in slow rate afib for several months (long story). Consequently, I needed a one jolt, 200J ECV. When or how soon to go to the hospital or contact your EP is a good question. May depend on how often you have episodes and what you history/routine is of self-converting. GeorgeN's post is a good example and he has a routine down pat. Perhaps another consideration is how fast is the afib. My afib episodes have always be on the slow side--80 bpm or so and with one episode never leaving the 60's but very irregular. With regard to rate, with my health profile, I have generally been advised to trek over to the ER sooner if the rate became excessively high. For me, excessively high was defined at about a steady 150 bpm. Anyway, that could be a consideration. I have read posts suggesting that trips to the ER on a weekend/holiday etc. is sometime useless as you may just be sent back home and told to get in touch with your EP the next day or whatever. Although, I have changed providers, my former EP/PA was comfortable in my e-mailing in a KARDIA strip for him to look at and then have himself or the nurse give me a call back. That takes a bit of pre-communication but it might be something for you discuss with your provider and see what their policy is with doing something like that. Stay safe.

I've been cardioverted 15-20 times. It's been early in the first hour of the episode and as long as 5 days. With the way cardioversions work, it's not going to matter whether you're early or late in the episode. It will either work or it won't.

I don't know if 24 hours is going to be your new normal, but progression of AF is the norm, not the exception.

I was ECV Thursday after 48+ hours of AF and flutter. This was my longest episode. If it wasn’t for delaying a day for covid19 testing, I wouldn’t had to return the next day. I was told for flutter less joules are used. It was my 3rd ECV since May 17. Usually 50 joules work. Maybe it was waiting more than 48 hours. Who knows.,The chief of cardiology who did the last ECV tried 50 joules but it didn’t work this time so they shocked me with 100. I felt “off” afterwards but I feel good today. Steady heart so far.

Curious why people choose to get cardioverted if you will self convert. Seems like people (generally) convert in a pretty set amount of time. I always self converted within 12-18 hours and would just let that happen. Getting zapped right away seems excessive and expensive.

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keeferbdeefer
Curious why people choose to get cardioverted if you will self convert. Seems like people (generally) convert in a pretty set amount of time. I always self converted within 12-18 hours and would just let that happen. Getting zapped right away seems excessive and expensive.

I was told the longer I am in AF the more pathways will be created. I had AF/flutter over 48 hours the past three times because of the covid19 testing delays. I am symptomatic. I fall (lots of scalp stitches (4 times I was stitched up)—not good while on Eliquis to hit my head—get dizzy and am out of breath. You are fortunate you don’t mind AF and appear to be non symptomatic nor a fall risk. Not everyone is fortunate to self convert before 12-18-48 hours and are not symptomatic. “People generally “ doesn’t apply to me and I may not be alone.

Especially A-flutter which for me doesn’t self convert.

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GeorgeN
Curious if you've tried or thought about on-demand (PIP - Pill in Pocket) rhythm med like flecainide. If it works and you tolerate, seems like it would be something you could do at the very beginning of an episode. In my case, I've done this for nearly 16 years (including converting a 2 1/2 month episode at the beginning of that period). Any more, I've titrated my afib remission program to the point I have to do it very infrequently (twice in last two years, with the last time in April 2019).

George- remind folks that PIP is safer if they weigh more than 154 pounds. Otherwise if one is petite they run the risk of a deadly flecainide toxicity. Flecainide has such a box label.

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keeferbdeefer
Curious why people choose to get cardioverted if you will self convert. Seems like people (generally) convert in a pretty set amount of time. I always self converted within 12-18 hours and would just let that happen. Getting zapped right away seems excessive and expensive.

Because you never know.
What will you do if you don't self convert after 18-20h? It's not that long, but...
I've about 1 episode a week and usually self convert within two hours. If I don't, after 2h-2h30 in afib, I take a dose of Pradaxa. And when I do so, I always self convert within some minutes. Ridiculous ? Maybe. But I never know for sure, so I take my Pradaxa. And some minutes later, I say : had I known, I would not had taken it.
330 episodes in less than five years, but I still don't know what will happen.

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susan.d

Curious why people choose to get cardioverted if you will self convert. Seems like people (generally) convert in a pretty set amount of time. I always self converted within 12-18 hours and would just let that happen. Getting zapped right away seems excessive and expensive.

I was told the longer I am in AF the more pathways will be created. I had AF/flutter over 48 hours the past three times because of the covid19 testing delays. I am symptomatic. I fall (lots of scalp stitches (4 times I was stitched up)—not good while on Eliquis to hit my head—get dizzy and am out of breath. You are fortunate you don’t mind AF and appear to be non symptomatic nor a fall risk. Not everyone is fortunate to self convert before 12-18-48 hours and are not symptomatic. “People generally “ doesn’t apply to me and I may not be alone.

Especially A-flutter which for me doesn’t self convert.

I wonder if that's true about the pathways when talking about episodes of a day or less. I have heard that once you're in perpetual afib, the chances of ablations working are much less due to the more established and new pathways. Not sure if short duration events create pathways as well. The concern my EP always had about longer than 24 hours was a blood clots of course. Not an increased number of pathways being created. Interesting point you make though. It does make some intuitive sense.

I agree with Keeferbeefer line of reasoning here. If you are most likely to self-convert, that is the safer way to go. There is a risk of the shock/blast knocking a small clot loose from the walls of the heart during ECV. Also a small chance the Hospital (ER I presume) would make a mistake administering the procedure/anesthesia. The decision to ECV, would be if you had gone past your normal conversion time, and looked like you would be in AFIB indefinately.

If the decision is indeed made to ECV, there is much to consider. In my case, since I am persistent 70% of the time, I wait 36 hours to see if I will self-convert, then try to get ECV'd between 40-48 hours, before the 48 hour window has passed. After that I would need to schedule a TEE/ECV as an outpatient because I do not take Anticoagulants when in NSR.

If the ER staff knew you were likely to self-convert in a day or so, they would probably not want to perform the ECV.

"I'm wondering if I should wait a while...maybe give it 12 hours before attempting cardioversion."

Yes, unless you are horribly symptomatic. Reasons for waiting a little while include allowing time for rate-control and blood thinning medication to take hold, as well as allowing time for the body to correct any acute physiologic or metabolic imbalances. The fact that you are self-converting after a period of time shows that that this is probably what is going on.

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susan.d
George- remind folks that PIP is safer if they weigh more than 154 pounds. Otherwise if one is petite they run the risk of a deadly flecainide toxicity. Flecainide has such a box label.

The max dose for flec is 200 mg for those under 70 kg (154#) and 300 mg for those over. This is something to discuss with your EP and clearly if you weigh a lot less than 70 kg, then the discussion of whether you should reduce this max even more. I know Susan had a problem at 120 something pounds and her doc gave her 300 mg, as I recall.

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susan.d
I was told the longer I am in AF the more pathways will be created.

My philosophy, since my 2 1/2 month episode nearly 16 years ago, has been to do whatever I can to minimize time out of rhythm. Hence the moment I know I'm out of rhythm, which is usually immediately unless I'm asleep, I chew my PIP dose of flec. It generally converts me in an hour or two. This is also what I advised my son in law. He initially wasn't taking afib that seriously. I arranged a call with Shannon and we convinced him he had an opportunity, that could evaporate, before things seriously progressed. He implemented the lifestyle changes we suggested, especially on alcohol consumption, he also changed his exercise protocol and added in electrolytes. Lastly, he asked for and received a script for PIP flec. To Susan's point, after getting the script, he lost about 15 pounds, dropping him significantly below the 70 kg cutoff. When my daughter told me this in February, I immediately texted him and told him to limit any flec intake to 200 mg. Fortunately, he's only needed to use the flec once since he got serious about all this, in January. Again, this is what we suggested for my son-in-law.

In addition to luck, limiting my time out of rhythm may be why my afib has not progressed.

Thank you George for your post!! I lost weight since but my flecainide overdose was when I weighed 121 pounds. The charge nurse @ICU told me I was lucky to be alive. Flecainide is not as harmless as you think.

Regarding others who advise to take rate control drugs vs running to get ECV, with Multaq-one cannot take any beta blockers while on the drug and my A-flutter did not self convert after 48 hours. In fact, I had to be shocked twice the last time to rid the flutter. Nasty burn.